Physician: Post-Institutional Medical Issues

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What are the most common medical issues among post-institutionalized children?

Generally, children that are placed for international adoption are placed because of a multitude of reasons. They are rarely if ever placed because they come from intact family networks with perfect family medical and past medical history. These children are placed because of abandonment, poverty, illness or death of parents, or severe familial dysfunction (such as drug abuse, alcoholism, child abuse and or neglect). All of these conditions can bring on a multitude of health conditions in a child. Children that have been referred to for international adoption may have also encountered a lack of healthcare and immunizations, poor prenatal care and early childhood neglect.

Some of the major health problems encountered in these children may include malnutrition, lice, tuberculosis, intestinal parasites, minor congenital defects, developmental delays scabies, and severe infections such as hepatitis (A, B, C) and HIV infection or AIDS and syphilis. The overall emotional and psychological health of the child that live in an orphanage for a prolonged period of time can be affected. If the child is placed in the hostile institutional care setting, with little social interaction, and no stable maternal figure, the critical emotional and psychological development is disrupted. It is because of this abnormal normal the living arrangement that future emotional and psychological conditions such as (reactive attachment disorder, sensory integration dysfunction, ADHD, posttraumatic stress disorder) can develop even after the child is adopted and placed into an intact family unit.


After a family receives a referral, it is very important that they have all of the available medical information (medical records, videotapes, pictures) evaluated by a physician who has an interest and experience in interpreting international medical documents. Growth parameters need to be plotted on standard growth charts, screening laboratory tests need to be interpreted, and medical diagnoses found on the chart needs to be evaluated in order to determine if they are significant or not. After speaking with many families about their referrals, I have found a universal question that is asked of me. Are all of these diagnoses that I found on the Russian medical report are common and can be easily dismissed.? I agree that many times many times the diagnosis is placed without supporting data; they should not be dismissed just because they are on many reports.. Only a trained physician is able to determine if a particular diagnosis a significant or not. I always state, "this diagnosis can mean something or it can mean nothing, we need to investigate it further and figure it out” When I perform a pre-adoption evaluation, I sometimes feel more like a detective rather than a physician.

The role of the pre-adoption evaluation is not to pick out the child for family. Its role is more of an educational role empowering parents with the knowledge in order to make an informed decision whether to adopt or not adopt that particular child.

Health problems seen in children placed for international adoption 1) General infections such as hepatitis, HIV infection, syphilis and intestinal parasites, skin parasites (scabies, lice) can be encountered in these kids. Blood screening tests are used to determine if the child has or was exposed to HIV, syphilis and or hepatitis. The vast majority of countries open for international adoption provide these results in your child's medical history. These tests are not diagnostic of any illness and should only be used as a screening tool. It does not mean that the child will not be exposed to the disease after the test was taken. Generally it is reassuring to have a negative screening test. It just means that the likelihood of the child actually having one of these illnesses is low. Upon arrival to the U.S.,a repeated HIV, hepatitis, and syphilis test need to be performed upon arrival and after six months. Intestinal parasites are also commonly found in children with that live in overcrowded quarters. Giardia infection is found in the stool specimen of many children. It is easily treated after the child comes home. 2) Fetal alcohol syndrome is a common risk factor in eastern European countries and in Russia. It should is not as common in Asia where alcohol consumption is not a societal norm. fetal alcohol occurs when the fetus is exposed to alcohol during the pregnancy. Fetal alcohol is a cluster of related problems. There is no one specific test to determine exposure. Some of the common characteristics this entity are listed below:

  1. Small head circumference and brain size (microcephaly)
  2. Mental retardation and developmental delay
  3. Abnormal behavior such as short attention span, hyperactivity, poor impulse control, extreme nervousness and anxiety.
  4. Visual difficulties
  5. Slow physical growth before and after birth
  6. Distinctive facial features such as:
    • flat nasal bridge
    • within the upper lip
    • short upturn nose
    • smooth skin surface between the nose and upper lip (missing philtrum)
    • small eye openings
While the actual diagnosis of fetal alcohol syndrome or fetal alcohol effect cannot be definitively made during the pre-adoption evaluation, suspicion or risk may be determined.

3) Reactive attachment disorder is a condition in which a child has great difficulty forming last thing, loving relationships. It usually results from neglect or abuse or because the child has not formed a bond with a parent or primary caregiver. If his condition occurs as a child its older he or she is unable to sustain healthy relationships with anyone. The risk for RAD can be minimized if the ratio of caregivers to children as low. A good ratio is one caregiver for every three or four children; the bad ratio is one caregiver for every 20 children. When evaluating videotape, one can look for evidence of how the child interacts with other people.

4) Sensory integration dysfunction can result when babies are unable to explore their surroundings and are left alone in the cribs for long periods of time and do not receive the loving touch of a caregiver. As a result, the body senses interpret information inappropriately. For example, the nervous system can over react to heat and cold or noise, bringing out hostility, withdraw, and clumsiness in the child. This disorder can be treated to therapy and provided by an occupational therapist. It is very hard to tell from the video if the child has sensory integration dysfunction.

5) Tuberculosis: generally children have exposure to bacteria and not active disease of the lung. Children found to have been exposed, through a positive PPD screen, all children are placed on prophylactic treatment with Isoniazid for nine months. This regimen helps to prevent the spread of the disease to the lungs.

6) Immunization status: some children may have some immunizations (hepatitis b, polio, DTP) but many times they have nothing.

7) Malnutrition and neglect

8) Developmental delay and growth delay

9) Rickets secondary to poor nutritional intake and lack of sunlight

10) Physical in central abuse

11) Lead poisoning

As you can see, children available for international adoption may have a wide array of potential health problems. It is reassuring to know that most of these health problems faced by these children can be effectively treated with modern medicine. The only problem is that you may not know the child's health problem until you have returned home. If the child's medical history and video tape look good to it would be prudent to have these documents evaluated by a physician in order to determine if” can this be something or is it nothing”

by George Rogu, M.D.

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Disclaimer

The information and advice provided is intended to be general information, NOT as advice on how to deal with a particular child's situation and or problem. If your child has a specific problem you need to ask your pediatrician about it - only after a careful history and physical exam can a medical diagnosis and/or treatment plan be made. This Web site does not constitute a physician-patient relationship.

This material has been provided by AdoptionDoctors.com, an innovative adoption medicine private practice and educational service, dedicated to helping parents and adoption agencies with the complex pre-adoption medical issues of internationally adopted children. All medical interactions are performed via, e-mail, express mail, telephone, and fax. There is no need to make a live appointment or travel outside of your hometown. For more information, visit AdoptionDoctors.com or call 631-499-4114.

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